Innovation–Achievement–Success

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​​​​​Collaboration​

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​The North East CCAC and North East Specialized Geriatric Services (NESGS) deepened their relationship this past year with the establishment of a combined care model, which paired a CCAC Complex Care Coordinator with the NESGS team. Working out of the same office helped improve communication an​​d information sharing, and allowed staff to coordinate patient visits, which resulted in fewer assessments for geriatric patients seeking appropriate medical and community supports.

"We have an important mutual goal – to provide the best possible community care for our geriatric patients so that they can age in place for as long as possible."

Marta Milks, Care Coordination Manager​ ​

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​The Telehomecare and Emergency Medical Services (EMS) teams in the Sudbury-Manitoulin region joined forces this year to help suppo​rt people living with one or more chronic illnesses in their homes. Established in 2012, the CCAC Telehomecare program provides phone-based health coaching and remote symptom and vital sign monitoring to patients dealing with heart failure, chronic obstructive pulmonary disorder and/or diabetes. Now, 135 EMS paramedics have been trained to install the health monitoring equipment, allowing them to perform an initial home visit and assessment and reporting their findings directly to the Telehomecare nurse.

​​"By coming together, we can provide an enhanced service for these patients far beyond the original vision for each of our programs."

Tammy Windsor, Telehomecare Program Manager

If at any point in their care, the Telehomecare nurse became concerned with a patient's health status, EMS was notified and a home visit was scheduled. This early intervention often resulted in patients receiving the assistance they needed in their homes, and avoiding an unnecessary trip to the ER.

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​The North East became the first CCAC in Ontario to increase its purchasing power by joining hospitals and other health care providers in negotiating supply contracts as a group through HealthPRO, a national healthcare procurement services organization.

"With growing demand for our services in the North East, we are always looking for innovative ways to achieve administrative savings so that we can direct more funds to frontline patient care."

Lisa Romanko, Procurement and Performance Management Director

​​​​In addition to saving money (an estimated 30% on regularly used products), the partnership with HealthPRO has created other benefits, such as retaining consistency in medical products between hospital and home, and smoother transitions and increased comfort for patients and caregivers.​

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Caregivers were also the focus of the North East CCAC's second Heroes in the Home camp​aign. Recognition events were held in Sudbury, North Bay, Timmins, Kirkland Lake and Sault Ste. Marie, with close to 70 volunteers nominated and recognized for their compassionate and caring support of a spouse, family member, neighbour or friend.​

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Kirkland Lak​e

​North Bay

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Sault Ste Marie

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Sudbury

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Timmins

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​The Patient-Centred Wound Care Program continued to develop and deepen partnerships between the CCAC and its contracted service providers in working towards quality improvement of wound care delivered across the North East. A two-prong approach ​–patient education and specialty clinical training – achieved remarkable results, including faster healing, increased patient comfort and satisfaction, and a significant decrease in the number of patients requiring extensive nursing for wound care.

​The team also introduced a series of 'pop up' wound care clinics this year, offering patients with chronic wounds and/or daily wound care needs an individual physical examination, followed by an information session specific to their wound type.

"The patients were very receptive to the information they received. These clinics have created a good forward momentum in their care."

Melanie Tulini, Engagement Lead

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